National Transportation Safety Board Aviation Accident Final Report

Transcription

1 National Transportation Safety Board Aviation Accident Final Report Location: TEMPLE BAR, AZ Accident Number: Date & Time: 12/10/1991, 1642 MST Registration: N350MR Aircraft: PIPER PA Aircraft Damage: Destroyed Defining Event: Injuries: 5 Fatal Flight Conducted Under: Part 135: Air Taxi & Commuter - Scheduled Analysis THE COMMUTER FLIGHT WAS ENROUTE TO ITS HOME AIRPORT AND OVER MOUNTAINOUS TERRAIN WHEN IT ENCOUNTERED LOW CEILINGS AND RAIN SHOWERS. THE AIRPLANE WAS NOT CERTIFICATED FOR IFR COMMUTER FLIGHTS. INSTEAD OF GOING TO AN ALTERNATE AIRPORT THE PILOT ATTEMPTED TO MAINTAIN VISUAL CONDITIONS AND REQUESTED AND RECEIVED A VISUAL CLEARANCE INTO THE TCA AND ADVISED THE CONTROLLER THAT HIS ALTITUDE WAS 5100 FEET MSL. HIS RADIO TRANSMISSION BECAME GARBLED DURING THE CLEARANCE READ BACK AND SHORTLY THEREAFTER THE CONTROLLER OBSERVED THE AIRPLANE'S RADAR TARGET TURN LEFT FROM ITS WESTERLY TRACK AND DISAPPEAR FROM HIS SCOPE. THERE WERE NO FURTHER COMMUNICATIONS BETWEEN THE PILOT AND THE CONTROLLER. WHEN THE AIRCRAFT FAILED TO ARRIVE AT ITS DESTINATION AN ALNOT WAS ISSUED. EARLY THE NEXT MORNING THE AIRCRAFT'S WRECKAGE WAS FOUND IMPACTED IN A MOUNTAIN APPROXIMATELY 10 MILES SOUTH OF COURSE AT AN ELEVATION OF 4100 FEET MSL. THE INVESTIGATION REVEALED THAT THE PILOT HAD PREVIOUSLY AND SUCCESSFULLY FLOWN THE ACCIDENT AIRPLANE IN IFR CONDITIONS. Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be: THE PILOT-IN-COMMAND'S POOR INFLIGHT DECISION BY NOT ELECTING TO PROCEED TO AN ALTERNATE AIRPORT AND TO CONTINUE TO THE FLIGHT UNDER VISUAL FLIGHT RULES INTO INSTRUMENT METEOROLOGICAL CONDITIONS. THE LOW CEILINGS AND VISIBILITIES ACROSS THE FLIGHT ROUTE AND THE MOUNTAINOUS TERRAIN WERE FACTORS IN THE ACCIDENT. Page 1 of 5

2 Findings Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATER Phase of Operation: MANEUVERING Findings 1. (F) TERRAIN CONDITION - MOUNTAINOUS/HILLY 2. (F) WEATHER CONDITION - LOW CEILING 3. (C) IN-FLIGHT PLANNING/DECISION - POOR - PILOT IN COMMAND 4. (C) NOT PERFORMED - PILOT IN COMMAND 5. (C) VFR FLIGHT INTO IMC - ATTEMPTED - PILOT IN COMMAND Page 2 of 5

3 Factual Information Pilot Information Certificate: Airline Transport Age: 44, Male Airplane Rating(s): Multi-engine Land; Single-engine Land Seat Occupied: Other Aircraft Rating(s): None Restraint Used: Seatbelt Instrument Rating(s): Airplane Second Pilot Present: No Instructor Rating(s): None Toxicology Performed: Yes Medical Certification: Occupational Pilot: Class 1 Valid Medical--no waivers/lim. Left Last FAA Medical Exam: 10/16/1991 Last Flight Review or Equivalent: Flight Time: 2972 hours (Total, all aircraft), 654 hours (Total, this make and model), 205 hours (Last 90 days, all aircraft), 37 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft) Aircraft and Owner/Operator Information Aircraft Manufacturer: PIPER Registration: N350MR Model/Series: PA PA Aircraft Category: Airplane Year of Manufacture: Amateur Built: No Airworthiness Certificate: Normal Serial Number: Landing Gear Type: Retractable - Tricycle Seats: 10 Date/Type of Last Inspection: 12/01/1991, AAIP Certified Max Gross Wt.: 7000 lbs Time Since Last Inspection: 13 Hours Engines: 2 Reciprocating Airframe Total Time: 7433 Hours Engine Manufacturer: LYCOMING ELT: Registered Owner: Installed, activated, aided in locating accident FAIRCHILD FEDERAL CREDIT UNION Engine Model/Series: Rated Power: Operator: LAS VEGAS AIRLINES, INC. Operating Certificate(s) Held: TSIO-540-J2BD 300 hp Operator Does Business As: Operator Designator Code: LVAA Commuter Air Carrier (135); On-demand Air Taxi (135) Page 3 of 5

4 Meteorological Information and Flight Plan Conditions at Accident Site: Instrument Conditions Condition of Light: Night/Dark Observation Facility, Elevation: LAS, 2174 ft msl Observation Time: 1650 MST Distance from Accident Site: 26 Nautical Miles Direction from Accident Site: 259 Lowest Cloud Condition: Scattered / 3000 ft agl Temperature/Dew Point: 11 C / 7 C Lowest Ceiling: Overcast / 6000 ft agl Visibility 35 Miles Wind Speed/Gusts, Direction: 5 knots, 170 Visibility (RVR): 0 ft Altimeter Setting: 29 inches Hg Visibility (RVV): 0 Miles Precipitation and Obscuration: Departure Point: GRAND CANYON, AZ (GCN) Type of Flight Plan Filed: Unknown Destination: LAS VEGAS, NV (VGT) Type of Clearance: None Departure Time: 1601 MST Type of Airspace: Class G Wreckage and Impact Information Crew Injuries: 1 Fatal Aircraft Damage: Destroyed Passenger Injuries: 4 Fatal Aircraft Fire: On-Ground Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 5 Fatal Latitude, Longitude: Administrative Information Investigator In Charge (IIC): James A Wall Adopted Date: 04/23/1993 Additional Participating Persons: Publish Date: Investigation Docket: ASI DALE NELSON; LAS VEGAS, NV GREG ERICKSON; WILLIAMSPORT, PA TIM HARDEE; OLATHE, KS NTSB accident and incident dockets serve as permanent archival information for the NTSB s investigations. Dockets released prior to June 1, 2009 are publicly available from the NTSB s Record Management Division at pubinq@ntsb.gov, or at Dockets released after this date are available at Page 4 of 5

5 The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. Page 5 of 5